The Commission on Care is calling for a transformation in health care for veterans, with expanded options for community medical treatment and a new governing board to oversee the nation's largest health-care system.(Photo11: H. Darr Beiser/USA TODAY)

A national commission assigned to come up with reforms for the Department of Veterans Affairs is calling for a transformation in health care for veterans, with expanded options for community medical treatment and a new governing board to oversee the nation's largest health-care system.

A commission report contains 18 recommendations to achieve a "bold transformation of a complex system that will take years to fully realize," adding, "We believe these recommendations are essential to ensure that our nation's veterans receive the health care they need and deserve, both now and in the future."

In a document that was scheduled for release Wednesday but was leaked Tuesday, the Commission on Care confirmed prior findings that the Veterans Health Administration suffers "many profound deficiencies," especially with access to care, and those maladies require "urgent reform."

The 292-page report was endorsed by 12 of 15 commissioners. Three members declined to sign, two of them issuing a dissent letter that says the findings and recommendations fall "far short of what is needed" to fix a veterans' health-care system widely regarded as broken.

The commission's majority concluded that the so-called Choice Program, created by Congress to let veterans seek private care when timely medical appointments are not available in VA clinics, is flawed in design and execution. Instead, the commission proposes a new community network of care for all veterans, regardless of wait times or geographic locations. That system would include Department of Defense medical facilities and other federal health providers, as well as private doctors and hospitals credentialed by the VHA.

Under the Choice Program, veterans now qualify for outside care only if they face a wait of more than 30 days for a VA appointment or reside more than 40 miles from the nearest VA clinic. The commission proposes to eliminate those restrictions while granting the highest access for veterans with service-connected conditions.

That "fundamental, dramatic change" apparently would eliminate two middleman firms that were contracted by VHA through the Choice Program to operate a nationwide network of private providers, booking appointments for qualified veterans. Arizona-based TriWest Healthcare Alliance is one of those firms.

One of the report's key proposals calls for creation of an 11-member board of directors, accountable to the president and responsible for overall governance of the Veterans Health Administration. The board would work with a proposed new administrator, chief of the VHA Care System, who would be appointed to a five-year term by the president.

Rep. Jeff Miller, R-Fla., chairman of the House Committee on Veterans’ Affairs, said it would take time to digest the full report, but he noted "the document makes it abundantly clear that the problems plaguing Department of Veterans Affairs medical care are severe. Fixing them will require dramatic changes in how VA does business, to include expanding partnerships with community providers in order to give veterans more health care choices."

Miller said his committee would review the report in detail at a September hearing.

The Commission on Care was created under a $15 billion reform law, the Veterans Choice, Access and Accountability Act of 2014, amid the nationwide furor over delayed care for veterans. The controversy erupted first within the Phoenix VA Healthcare System, where employees reported that patients were dying while awaiting appointments, and that administrators were issuing phony wait-time data while collecting bonuses.

Revelations in Phoenix led to inquiries across the country by Congress, the Government Accountability Office, the VA Office of Inspector General and the U.S. Office of Special Counsel. Those probes generally verified that untimely care, false data and problems with transparency, whistle-blower retaliation and accountability were systemic throughout the VA.

Secretary Eric Shinseki resigned amid the furor and was replaced by Bob McDonald. Phoenix VA Health Care System Director Sharon Helman was fired, along with several other top administrators.

After nearly a year of meetings, testimony and analyses, the commission concluded that the Veterans Health Administration offers care that is "in many ways comparable to or better in clinical quality" than what is available in private hospitals. However, members concurred with an Independent Assessment Report that determined the VA is plagued by "chronic management and system failures, along with a troubled organizational culture."

Commissioners stressed that the proposed reforms cannot be treated as "piecemeal fixes," but must serve as a "foundation for far-reaching organizational transformation." For example, they stressed that the VHA has no qualified senior executive to oversee information technology and operates with "antiquated, disjointed clinical and administrative systems" that affect all other programs.

The commission members were appointed by congressional leaders and the president. Chairwoman Nancy Schlichting is chief executive officer of the Henry Ford Health System.

In the dissent letter, Commissioners Darin Selnick and Stewart Hickey wrote: "The commission's final report is largely a hodgepodge of perfunctory recommendations that, while well meaning, will do little to redirect the VHA's troubled trajectory. The central problem is that these recommendations focus primarily on fixing the existing VHA provider operations, rather than boldly transforming the overall veterans’ health care system.”

Selnick and Hickey said the report will stand as a “monument to a lost opportunity for the bold reform that the VHA needs, and that veterans deserve.”

Selnick is a former VA employee and adviser to Concerned Veterans for America, which advocates a complete transformation of the VHA into a federally chartered non-profit enterprise with an open-choice system for veterans. Hickey is former health-center administrator and past executive at AMVETS, a service organization with about 250,000 members.

Selnick, an Air Force veteran, told USA TODAY that the commission never adequately researched a larger overhaul of VA health care including transforming it into an insurance-type program that would pay for rather than directly provide health care. He also said the commission never voted on which provisions would be included, and the chairwoman declined to include the dissent letter with the final report.

Schlichting could not be reached immediately for a response to those criticisms.

The commission's final report will be submitted to Secretary McDonald and President Barack Obama on Wednesday. Under the Choice Act, the president has 60 days to submit a congressional report assessing the findings and recommendations.

Concerns over wait times at VA facilities date back to 2012, when GAO noted problems.

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Early 2012

Early 2012: Dr. Katherine Mitchell, a Department of Veterans Affairs emergency-room physician, warns Sharon Helman, incoming director of the Phoenix VA Health Care System, that the Phoenix ER is overwhelmed and dangerous. Mitchell now alleges she was told within days by senior administrators that she had deficient communication skills and was transferred out of the ER.

Later 2012, March 2013

Later in 2012: Later in 2012: The U.S. Department of Veterans Affairs orders implementation of electronic wait-time tracking and makes improved patient access a top priority. In December, the Government Accountability Office tells the Veterans Health Administration that its reporting of outpatient medical-appointment wait times is "unreliable," that scheduling policies are not uniform nationwide and that improvements are needed.

March 2013: The GAO's Debra Draper tells a subcommittee of the House Veterans' Affairs Committee: "Although access to timely medical appointments is critical to ensuring that veterans obtain needed medical care, long wait times and inadequate scheduling processes at VAMCs (medical centers) have been persistent problems, as we and the VA Office of Inspector General have reported."

July 2013

July 2013: In an e-mail exchange among employees at the Carl T. Hayden VA Medical Center in Phoenix, an employee questions whether administrators are improperly touting their Wildly Important Goals program as a success because it shows a dramatic reduction in wait times for patient appointments.

"I think it's unfair to call any of this a success when veterans are waiting six weeks on an electronic waiting list before they're called to schedule their first PCP (primary-care provider) appointment," program analyst Damian Reese complains. "Sure, when their appointment was created, (it) can be 14 days out, but we're making them wait 6-20 weeks to create that appointment. That is unethical and a disservice to our veterans."

September, October 2013

September 2013: Mitchell files a confidential complaint intended for the VA Office of Inspector General, channeled through Arizona Sen. John McCain's office. Her list of concerns instead goes to the Office of Congressional and Legislative Affairs and eventually back to the VA, which responds in February 2013. It does not address her most serious complaints. Mitchell, meanwhile, is placed on administrative leave.

October 2013: Dr. Sam Foote, a doctor of internal medicine at the Phoenix VA, files a complaint with the VA Office of Inspector General alleging purported successes in reducing wait times stem from manipulation of data, not improved service, and that vets are dying while awaiting appointments for medical care.

December 2013, April 2014

December 2013: Foote retires, assuming the role of whistle-blower by meeting with Arizona Republic reporter Dennis Wagner. He details allegations that patients have died while awaiting care at the Phoenix VA and that wait times have been falsified. The same month, inspector general's investigators visit Phoenix to look into whistle-blowers' complaints.

April 9: Rep. Jeff Miller, R-Fla., chairman of the House Committee on Veterans' Affairs, says during a hearing that dozens of VA hospital patients in Phoenix may have died while awaiting medical care. He says staff investigators have evidence that the Phoenix VA Health Care System keeps two sets of records to conceal prolonged patient waits for appointments and treatment.

April 2014

April 16: A Phoenix rally organized by Concerned Veterans for America and attended by Rep. David Schweikert, R-Ariz., draws 150 veterans and their supporters calling for solutions to the controversy.

May 2014

May 1: U.S. Secretary of Veterans Affairs Eric Shinseki places Helman and two others on administrative leave pending an outcome to the inspector general's probe.

May 2: Mitchell goes public with her allegations about mismanagement of the Phoenix VA system and her concerns about wait times, noting that she and a co-worker moved to protect some documents as evidence.

May 2014

May 5: The American Legion's national leaders call for Shinseki's resignation. Shinseki says he intends to stay put.

May 8: Shinseki orders records audits of all VA health-care facilities around the U.S. a day after U.S. Rep. Ann Kirkpatrick, D-Ariz., makes the request.

May 2014

May 9: McCain, R-Ariz., holds a veterans' town hall in Phoenix where he proposes a new system that would allow veterans to go outside the VA to seek private health care at government expense.

May 2014

May 12: Steve Young takes over as interim director of the Phoenix VA Health Care System.

May 2014

May 15: The U.S. Senate Committee on Veterans' Affairs holds a four-hour hearing. Acting Veterans Affairs Inspector General Richard Griffin reveals that the team probing complaints about Phoenix VA facilities includes criminal investigators.

May 16: Dr. Robert Petzel, the under secretary for health and second in command at the Department of Veterans Affairs, departs the agency. Shinseki says Petzel resigned, though the agency had announced Petzel's planned retirement last September.

May 2014

May 20: Officials disclose that White House Deputy Chief of Staff Rob Nabors will visit Phoenix for meetings with leaders of the Phoenix VA Health Care System.

May 21: President Barack Obama pledges in a televised press briefing that the administration will thoroughly investigate allegations of misconduct at VA facilities in Phoenix and across the country. He says he expects preliminary results of the review in Phoenix within a week and will punish any misconduct.

May 2014

May 28: The VA's Office of Inspector General releases a scathing interim report that confirms whistle-blower allegations of mismanagement and the manipulation of data related to patient wait times. Among the findings: Phoenix was reporting wait times of just 24 days, while the actual delay in appointments averaged nearly four months, and 1,700 veterans had signed up for initial appointments in Phoenix but did not appear on any wait lists. Investigators said it will take further analysis to determine whether any veteran deaths resulted directly from falsified records and prolonged waits.

Angry lawmakers on the U.S. House Committee on Veterans' Affairs blast three senior VA officials during a lengthy night hearing, accusing the agency of stonewalling and showing indifference to the suffering of veterans.

May 28-29: There is a renewed chorus of calls for Shinseki's resignation or ouster.

May-June 2014

May 30: Shinseki makes a speech in which he says he has begun the process for removing senior leaders at the Phoenix VA, and apologizes to all veterans and the nation for the scandal involving the systemic delay of health care to veterans. Obama later meets with Shinseki where the VA secretary offers his resignation. Minutes later, the president announces he accepted Shinsenki's resignation "with considerable regret." Obama names VA Deputy Secretary Sloan Gibson as interim head of the department while he selects a permanent replacement. He pledges to veterans "we will never stop working to do right by you and your families."

June 5: Gibson visits the Phoenix VA hospital. He tells reporters that 18 of the 1,700 Arizona vets who were seeking first-time appointments with primary-care doctors, but were excluded from the VA's electronic waiting list, died before they were contacted.

June 2014

June 9: The VA releases reports that finds VA medical centers nationwide have misrepresented or sidetracked patient scheduling for more than 57,000 former military personnel, and about 64,000 more were not even on the agency's electronic waiting list for doctor appointments they requested. Major reforms are announced, including an administrative hiring freeze, increased transparency and the cancellation of bonuses to employees who meet a goal for scheduling doctor appointments. An additional "front line" team is sent to Phoenix to immediately rectify problems with patient backlogs, appointment scheduling and record-keeping.

June 2014

June 10: The American Legion opens a four-day "crisis command center" at Phoenix Post 1 to offer assistance to Arizona veterans who have had difficulties trying to get appointments or other services through the Phoenix VA Health Care System. The center has a "triage team" to help veterans with benefits claims, enrollment in VA health care and bereavement counseling.

June 11: The U.S. Senate approves its version of VA reform legislation easing restrictions on the firing of senior VA bureaucrats and, like House legislation, making it easier for veterans to get care outside the VA system when backlogs develop. Cost is a key difference between the House and Senate bills, sending the matter to a conference committee.

June 23: Pauline DeWenter (left), a scheduling employee for the Phoenix VA Health Care System, goes public and discloses that she was the keeper of a "secret list" of local veterans who waited months for medical care. She accused others of altering records recently to try to hide the deaths of at least seven veterans awaiting care.

July 9: Glenn Costie, director of the VA Medical Center in Dayton, Ohio, temporarily takes the helm of the Phoenix VA, where he will serve through Nov. 6, then return to Ohio. He is the second temporary chief to take over in Phoenix.

July 11: Phoenix VA Health Care System officials brief congressional staffers on strides they've made in contacting patients who were awaiting medical appointments when the VA scandal erupted. They say hospital representatives contacted approximately 2,800 veterans and were still trying to reach about 300 others. Of those who were reached, nearly 2,700 who wanted appointments were scheduled within 30 days.

July 11: Phoenix VA Health Care System officials brief congressional staffers on strides they've made in contacting patients who were awaiting medical appointments when the VA scandal erupted. They say hospital representatives contacted approximately 2,800 veterans and were still trying to reach about 300 others. Of those who were reached, nearly 2,700 who wanted appointments were scheduled within 30 days.

July 24: Negotiations over the VA overhaul legislation erupt after weeks of mounting tension over how much to spend reforming the troubled agency. House Veterans' Affairs Committee Chairman Jeff Miller, R-Fla., and his Senate counterpart, Sen. Bernie Sanders, I-Vt., clash publicly after weeks of talks about merging parallel reform bills.

July 25: Members of Arizona's congressional delegation urge the VA to investigate allegations by a watchdog group that Elizabeth Freeman, acting director of the VA Southwest Health Care Network, retaliated against a whistle-blowing employee in her previous VA post in California.

July 2014

July 29: On the same day the U.S. Senate unanimously confirms Robert McDonald as the nation's next Veterans Affairs secretary, new audit findings from the Veterans Health Administration rip the VA health-care scheduling system as dysfunctional and dishonest.

July 31: The U.S. Senate approves the reform bill, sending it to President Barack Obama. The bill makes it easier for veterans to seek care outside the VA system if they live a long distance from VA facilities, or they cannot get a timely appointment through their VA center. It also makes it easier to fire VA employees, giving the new VA secretary more latitude to clean house.

Aug. 26: A long-awaited VA inspector general report says operations at the Phoenix VA Health Care System reflect "unacceptable and troubling lapses in follow-up, coordination, quality and continuity of care," and that a flawed appointment system "adversely affected the quality of primary and specialty care" for patients. But it stops short of unequivocally concluding that veterans died because they had been sidetracked on so-called "secret wait lists."

Sept. 11: Arizona's congressional delegation sends a letter to VA Secretary Robert McDonald urging him to name a permanent leader of the Phoenix VA medical center, saying it "would benefit from increased stability among leadership."

Sept. 17: At a contentious congressional hearing, VA Inspector General Richard Griffin dismisses whistle-blower charges of a cover-up, but concedes that delayed treatment for thousands of Arizona veterans may have contributed to some deaths -- a reversal of the message in his agency's August report.

Sept. 29: A Concerned Veterans for America task force is launched to evaluate challenges to delivering veteran health care and the role the VA should play in the wake of changes in the health care industry. The VA, meanwhile, reaches settlement terms with three Phoenix whistle-blowers who filed retaliation complaints after helping to expose mismanagement and health-care breakdowns at the Phoenix VA medical center.

Nov. 4: The VA names longtime administrator Glen Grippen as the third interim executive to oversee the Phoenix VA Health Care System since May.

November 2014

Nov. 24: Sharon Helman, director of the Phoenix VA Health Care System, was fired by the Veterans Affairs Department, nearly seven months after she and two high-ranking officials were placed on administrative leave amid allegations that 40 veterans died while awaiting treatment at the hospital.

December 2014

Dec. 22: An administrative judge upholds Helman's firing based on findings that she improperly accepted gifts and perks from an industry lobbyist.

Jan. 28: An inspector general's report finds that care for urology patients at the Phoenix VA remains so flawed that veterans' lives may still be endangered.

March 2015

March 13: President Barack Obama and his VA secretary visit the Phoenix VA to receive an update on efforts to improve.

October 2015

October: A scathing report on urology care at the Phoenix VA hospital says some sick veterans died awaiting care and hundreds were medically sidetracked or neglected because of short-staffing and mismanagement. The agency names Skye McDougall health-care director overseeing Southwest facilities. McDougall had been accused in spring 2015 of giving false testimony to Congress regarding patient wait times.

Oct. 16: A judge finds that Phoenix VA officials engaged in whistleblower retaliation against Tonja Laney, chief fiscal officer for the Phoenix VA medical center, when they suspended her, searched her office, and investigated her after she tried to expose financial wrongdoing and mismanagement.

November 2015

Nov. 11: USA Today discloses that the VA doled out more than $142 million in bonuses to executives and employees for performance in 2014, as the scandal was unfolding.

Nov. 19: An administrative judge rules that the VA cannot rescind a bonus paid to former Phoenix VA hospital Director Sharon Helman shortly before she was fired last year for misconduct.